Provider Demographics
NPI:1396929006
Name:JERRY M PAYNE D.C., INC
Entity type:Organization
Organization Name:JERRY M PAYNE D.C., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-452-3017
Mailing Address - Street 1:1217 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4301
Mailing Address - Country:US
Mailing Address - Phone:360-452-3017
Mailing Address - Fax:360-452-4100
Practice Address - Street 1:1217 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4301
Practice Address - Country:US
Practice Address - Phone:360-452-3017
Practice Address - Fax:360-452-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8851005OtherMEDICARE GROUP PIN
WAPA4216OtherREGENCE BLUE SHIELD
WA2022861Medicaid
WA0124952OtherDEPT OF LABOR & INDUSTRIE
WAG8851006Medicare PIN
WAG8851005OtherMEDICARE GROUP PIN